Pain And Palliation

Question 1

Describe the prescribing principles in analgesia

Answer 1

PO whenever possible
Regular dosing
Match drug and dose to pain
Individualised dose to patient factors
Patient centered decisions

Question 2

Describe the WHO pain ladder

Answer 2

Step 1 - paracetamol and NSAIDs
Step 2 - mild opiates
Step 3 - strong opiates
Step 4 - specialist interventions

Adjuvant drugs

Question 3

What are examples of adjuvant drugs given in WHO pain ladder

Answer 3

Neuropathic pain - gabapentin, pregabalin, carbamezipine

Corticosteroids, muscle relaxants, anti-spasmodics, bisphosphonates for bone pain

Question 4

What are some step 4 specialist pain mangement interventions

Answer 4

Nerve block
Epidurals
Spinal stimulation
PCA pump
Neurolytic block

Question 5

What is the MoA, contraindications and adverse effects of ibuprofen

Answer 5

COX2 inhibitor, blocks prostaglandin pathway.

Contraindicated in people with hx of gastric ulcer/bleeding, renal impairment, allergy to NSAIDs

Adverse effects: GI bleeding, renal impairment, hepatotoxicity

Interactions: do not use with anticoagulants

Question 6

Contraindications of paracetamol

Answer 6

Acute liver failure, severe renal impairment

Question 7

What are examples of weak opioids

Answer 7

Codeine, dihydrocodeine, tramadol

Question 8

Mechanism of action of tramadol

Answer 8

Opioid receptor agonist, and some antagonism of serotonin and NE receptors

Question 9

Contraindications of opioid drugs

Answer 9

Acute respiratory depression, comatose, head injuries, increased ICP

Question 10

Contraindications of codeine

Answer 10

Risk of paralytic ileus, acute ulcerative colitis

Question 11

Side effects of opioids

Answer 11

CNS: drowsiness, nausea, vomiting, confusion, respiratory depression, dependence, opioid induced hyperalgesia

Others: constipation, itchiness, hypotension, arrythmias, bronchospasms

Question 12

What is opioid induced hyperalgesia

Answer 12

Paradoxic adverse effects of opioids causing hypersensitisation to pain

Question 13

What are signs of opioid toxicity

Answer 13

Resp depression
Hallucinations
Pin point pupils
myoclonic jerks
Confusion

Question 14

When to administer naloxone?

Answer 14

Opioid toxicity: RR <8, hard to rouse, Sats <90%

Question 15

Why should tramadol not be given with SSRIs

Answer 15

Risk of serotonin syndrome

Question 16

Contraindications of morphine

Answer 16

Acute abdomen, heart failure due to lung disease, delayed gastric emptying, phaeochromocytoma

Question 17

What strong opioid can be used in poor renal function

Answer 17

Alfentanyl

Question 18

What are some considerations in palliative prescribing

Answer 18

Previous opioid use
Other drug use, chemotherapy
Renal/hepatic impairment
Route of administration
Nutrition/fluid status

Question 19

4 common types of drugs prescribed in palliative care

Answer 19

Analgesia - morphine/fentanyl

Antisecretions - hyoscine

Anti-emetic - cyclizine, haloperidol

Sedative - midazolam

Question 20

How to titrate morphine dose in chronic pain?

Answer 20

Start with suggested dose, and 1/6th to 1/10th 24hour dose for PRN break thru.

If uncontrolled, total up 24hr dose and adjust daily dose, no more than 50% increase in 24 hours

If controlled: convert to 12 hourly MR doses